patient can use crutches and bear weight as tolerated be sure the bottom of the cast is molded to accommodate the walker if the fracture is distal, the PTB cast with molding around the tibia condyles can be applied after the cast has partially dried, add soft roll and plaster to make it a long leg cast with the knee infive to 10° flexion well padded short leg cast is applied holding the fracture reduction surgeon may have to manipulate the fracture an assistant places his hands under the metatarsal heads to keep the ankle at 90° in neutral or slightly protonated position. gravity will often reduce the fracture patient is supported while sitting with the knee flexed 90° over the end of the table procedure for casting with minimal sedation operating room - if more sedation is needed or more manipulation is needed emergency room -is sedation is needed and reduction can be obtained with minimal manipulation office - if the fracture does not need reduction in the patient can sit with the knee flexed to 90° over the table. note: application of well molded cast can dramatically increase compartment pressures initial long leg cast be applied w/ knee in 0 to 5 deg flexion (more flexion will allow better rotation control of the fracture) less than 5 - 7 deg of internal or external rotation, varus or valgus less than 10-15 deg of anterior or posterior bowing on lateral film less than 5-10 deg of varus / valgus angulation when comparing tibial plateau to tibial plafond (some will not accept more than 5 deg of varus) ref: A more accurate method of measurement of angulation after fractures of the tibia. this author noted that the mechanical axis of the normal tibia may not pass down the center of the medullary canal When there is a question of whether the reduction is acceptable, x-rays of the opposite leg should be obtained as noted by Milner SA (1997), there is a considerable amount of tibial shaft alignment variety, and therefore, Radiographic Alignment (see: malunion of tibial frx) nonunion occurs in 2-5%, malalignment occurs in 3% to 8%, & shortening of more than 1 cm occurs in as many as 10% of patients 1-2 % refrx & 1-2 % require bone graft for union w/ stable frx avg time for union is 4 to 5 months, w/ range of 2 to 14 months more than 50% cortical comminution or displacement more than 50% are significant risk factors for non-union often the tibia will fall into varus w/ distal frx and will fall into valgus w/ proximal frx is a relative contra-indication to functional bracing due to the propensity for angulatory deformity initial shortening of more than 2 cm is contra-indication for casting, since this amount of shortening would be expected w/ wt bearing (despite success of initial reduction) infection: external fixation is used until prominent fixation can be accomplished. soft tissue wounds: open fractures should be treated by external fixation or intramedullary nailing comminution: internal fixation necessary Initial displacement and stability of reduction. Spiral fractures of the shaft of the tibia. refs: Fractures of the Tibial Shaft - a survey of 705 cases displaced spiral fractures of the distal third of the tibia are especially difficult to manage with casting unstable frxs of tibia may be treated by closed reduction & casting, however, malunion may occur more than 50% initial frx displacement will significantly increase risk of loss of reduction and non-union, due to instability of frx displacement: if the fracture fragments on are or can be opposed to 25% in a transverse fracture, casting or bracing is permissible indications - These are based on "personality" of the fracture as described by Nicoll EA (1964)
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